Prescription Form - GoodPeople Medical Centre

+353 412134182

Repeat prescription order form

Full Name

Address

Phone

Private patient/ GMS

GMS/DVOC

Number

Pharmacy

List of medication:

Name

Dosage

Quantity

Repeats

Please Note:

Please allow 3 working days for your request to be processed.
A Billink will be sent for Private Prescriptions, when this is paid the Prescriptions will be sent to the Pharmacy.
The GP may request to see the patient for review, when necessary, prior to repeating medication.

I confirm I have read the above points:

Signed

Date